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SAN JOAQUIN COUNTY <br /> ENviRoNmENTAL HEALTH DEPARTMENT <br /> 600 E.Maio St.,Stoddon,CA 93202-3029 <br /> T e:(209)469-3420 Fa (209)468-3433 Web:www.sj$ov.oWehd <br /> RETURN TO COMPLIANCE CERTIFICATION <br /> Any MINOR violations noted in the"Notice to Comply"in the attached Inspection Report must be <br /> corrected within 30 days of receipt of this inspection. This certification form must be submitted to the <br /> Environmental Health Department )address at the top of this form within 35 days of receipt of the <br /> Inspection Report. <br /> All corrections to other violations noted in the attached Inspection Report or Continuation Form,or <br /> disputes to any violations,are to be submitted using this certification and returned to EHD within 30 days <br /> unless otherwise specified in the Inspection Report. <br /> Nate: Ali EHD staff time associated with failing to comply by the above noted dates will be billa at <br /> the current hourly rate($115). <br /> For this certification t® be COmplete the operator of the site must include: <br /> • A statement documenting what coffective actions were taken or will be taken for each violation <br /> • Copies of sample 'fpaperwork,and/or photos <br /> verifying corrections <br /> • is certification <br /> Inspection Date: (o^`g® 1(D Ins By: @ye <br /> Facility Address: 1340 U). EPA ID#: Ca L 221?,q# <br /> r <br /> I certify under penalty of law that <br /> 1. I have corrected the violations ed in the Inspection Report from the above-mentioned <br /> inspection date. <br /> 2. I have personally examined the following documentation submitted as proof of compliance FOR <br /> EACH VIOLATION and I believe the information to be true,accurate,and complete: <br /> Photos 4or ork Statement <br /> 3. lain authorized to submit this certification on behalf of the Respondent <br /> 4. I am aware that there are significant for submitting&Ise information,including the <br /> possibility of a fine or imprisonment for known violations.(HSC 25191) <br /> Name: 1RUD WAAIM Title: ( . <br /> Signature.Z)A� -7,1-ID <br /> EHD 22-02-005 Rev 10-07 <br /> i <br />